Provider Demographics
NPI:1285809707
Name:KELLY DRUGS
Entity type:Organization
Organization Name:KELLY DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:LAURETTE
Authorized Official - Last Name:VAN HOVELN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-889-4326
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IL
Mailing Address - Zip Code:60953-0127
Mailing Address - Country:US
Mailing Address - Phone:815-889-4326
Mailing Address - Fax:815-889-4326
Practice Address - Street 1:105 E JONES ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IL
Practice Address - Zip Code:60953-1047
Practice Address - Country:US
Practice Address - Phone:815-889-4326
Practice Address - Fax:815-889-4326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540113353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid